Provider Demographics
NPI:1083663348
Name:PALMER, SAMUEL E (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:PALMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MORAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005
Mailing Address - Country:US
Mailing Address - Phone:478-988-1282
Mailing Address - Fax:478-988-3120
Practice Address - Street 1:106 MORAN DRIVE
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005
Practice Address - Country:US
Practice Address - Phone:478-988-1282
Practice Address - Fax:478-988-3120
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000374382KMedicaid
GA00374382I OR EMedicaid
GA08BDDPFMedicare ID - Type Unspecified
GA00374382I OR EMedicaid